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Rapid Responses: Rapid Responses published:
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The AIDS Mystery
- Robert G Holmes (11 September 2004)
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A blighted pearl
- Mark Struthers (12 September 2004)
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Medical Brain Drain - Zimbabwe, 1983 & Beyond
- Tristan J Martin (13 September 2004)
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Many medical students do leave developing countries after graduation
- Saw Sian Chin (14 September 2004)
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High Health Professional Attrition Rate in Africa
- Alex O. Otieno (14 September 2004)
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A multi-layered problem
- Christopher M Harris (17 September 2004)
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Robert G Holmes, Retired surgeon British Coumbia, Canada V1K 1P1
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I worked in rural Uganda (Mbale and Soroti) from 1960 to 1963, and was in daily contact with cases of advanced tuberculosis, anthrax, leprosy and a severe wasting disease which, in hindsight, was obviously AIDS. It was long before the days of disposable needles and surgical gloves. Everything was boiled and re-used. I look back on those days in wonder, and count myself lucky that my family and I have survived to this day; my wife did, however, suffer West Nile encephalitis and my colleague awoke one morning with a painful eruption on his palms and soles, which was diagnosed by a senior physician as alastrim (Minor smallpox). Competing interests: None declared |
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Mark Struthers, GP Bedfordshire, UK
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This paper by Yoswa Dambisya, along with the edidorial by Dan Ncayiyana, stunned me. I had not realised the impact of HIV infection on health professionals in Africa and had thought they might be relatively immune compared to the devastation in the general population. It is surprising to learn that death has been a bigger drain on brains than emigration among the 1984 Ugandan graduates. That 30% of graduates from the Makerere Medical School should have died over this two- decade period is clearly very disheartening. It is so sad too that six (8%) of the deaths were due to suicide – five related to fear of HIV positivity. The implications for the Ugandan health system (and for other countries in Africa) are very sobering indeed. It is heartening that a high proportion of Ugandan doctors support their country in the public sector and this gives extra hope for Uganda’s future prosperity. Competing interests: A great affection for the country and people of Uganda, land of my birth |
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Tristan J Martin, General Practitioner Wells City Practice, Wells, Somerset, BA5 1XJ
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Yoswa Dambisya's analysis [1] of the fate and career paths of Makerere graduates from 1984 differs somewhat from the Zimbabwean experience. I graduated from the University of Zimbabwe's Godfrey Huggins School of Medicine in 1983 and left Zimbabwe in 1989 to work in the UK. In 1997 I established a website [2] as a contact point for graduates of the medical school in Harare and currently have the contact details of more than 400 graduates. The path followed by those in my class, and graduates in subsequent years, is reviewed below. Fifty-five doctors graduated in 1983. I have had recent direct contact with 32 of them, and have received reliable information concerning another 14. No information is available on the remaining nine. There has been only one death (1.8%) compared to the 22 deaths (28.6%) out of 77 graduates mentioned by Dambisya. By contrast with the Ugandan graduates, only 5 (9%) are known to still be working in Zimbabwe. Six (11%) are in South Africa, one elsewhere in Africa, 12 (21.8%) in the UK, 12 (21.8%) in USA and Canada, 7 (12.7%) in Australia and New Zealand and one in the Far East. Twenty-three are known to have specialised and are working in Consultant level or equivalent posts and five are working in General Practice. Two no longer work in medicine having switched careers. More recent graduates have shown a similar tendency to leave Zimbabwe. Details of 226 doctors who graduated between 1984 and 2000, and who have made contact via the website, were examined. Forty-four (19.5%) are in Zimbabwe, 38 (16.8%) in South Africa and 8 (3.5%) are working in other African countries. The remainder show a similar distribution to that of my own class, with 61 (27%) being in the UK, 46 (20.4%) in North America, 18 (8%) in Australia and New Zealand and 11 (4.9%) spread around the rest of the world. For a variety of reasons, Zimbabwe loses a large proportion of the doctors that it trains to other countries. References 1. Yoswa M Dambisya. The fate and career destinations of doctors who qualified at Uganda's Makerere Medical School in 1984: retrospective cohort study. BMJ 2004; 329: 600-601 2. Zimbabwe Medical Graduates Worldwide website. http://www.btinternet.com/~zimdocs/index.html Competing interests: TJM is one of the 1983 graduates, has joined the brain drain, and runs the Zimbabwe Medical Graduates Worldwide website. |
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Saw Sian Chin, Paediatrician 93150 Kuching, Malaysia
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I agree with Dr. Martin that in the developing countries with low incidence of HIV, medical students do leave their countries after graduation. I was in the Gambia in 2001-2002, when there is a new medical school being set up. The majority of medical students had already made plans of going overseas before they even graduate. On the other side of Africa, where my friend was a volunteer in Uganda, he also observed a lot of young professionals, nurses and doctors died from HIV related illness and crippled the health service. Competing interests: None declared |
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Alex O. Otieno, Instructor Arcadia University, Glenside, Pennsylvania
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It is no surprise that health professionals in areas with endemic diseases or conditions face the same challenges as their patients. This applies to vector-borne diseases such as malaria, infectious Hepatitis B and C and even injurties sustained from motor vehicle accidents. However, the mortality rates adduced by Yoswa M Dambisya (BMJ 2004; 329: 600-601) are disturbing given the expected higher levels of education and access to resources such as anti-retrovirals that prolong lives of those living with human immune deficiency virus/acquired immune deficiency syndrome (HIV/AIDS). The challenge that those interested in solving the problem of attrition among health professionals must contend with is thus one that is multi-faceted. Assuming the trends are reversed in the HIV/ AIDS arena with the declining infection rates in countries such as Uganda, the challenge of brain drain will continue to rear its ugly head. Given the poor compensation that health professionals receive in most sub-Saharan African countries, the prospect of reversing the flight of physicians and nurses to western countries is rather low. Clearly, we must address the myriad issues that facilitate flight and address the conditions that make doctors and other health professionals vulnerable to disease. A comprehensive approach that addresses questions of work conditions, and remuneration and explores the possibility of collaboration with colleagues in the west might be a starting point. Since it is untenable to prohibit African health professionals from migrating, there is an urgent need for strategies geared towards engaging who practice in the UK, the US and other countries in resource mobilization and linking them with other stakeholders. Competing interests: None declared |
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Christopher M Harris, Medical Student Glasgow University G12 8QQ
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I have just completed a 9 week elective at a rural hospital in Kasese (south west Uganda). The worrying statistics presented by this article came as little surprise to me after witnessing the lack of facilities available throughout Uganda. Many of the problems described by Robert G Holmes still exist, with equipment being reused (even if intended to be disposable). Another problem is that there are no anti-retroviral drugs available, even for prophylaxis. Most doctors i spoke to feared their introduction, stating that in the face of current lack of education it would lead to an even greater infection rate as individuals would remain healthier for longer and would still be unaware of their infectious potential. Contraceptives are also hard to find in the small villages where HIV/AIDs is rife. Even amongst the medical profession, the use of contraception was often frowned upon, particularly by the older generations. In saying that, there were several medical students in the hospital and they were often responsible for whole wards with little or no support and they seemed to cope very well. This, I think, is a testament to the training they are given in medical school, in that many of us from the UK would struggle in the same situation. Competing interests: None declared |
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